Rhode Island Pediatric Patient Centered Medical Home Initiative February 7, 2013

Rhode Island Pediatric Patient
Centered Medical Home Initiative
February 7, 2013
4:30-6:00 PM
Introductions
• Patricia Flanagan, MD, Co-Chair, Hasbro
Children’s Hospital
• Elizabeth Lange, MD, Co-Chair, Waterman
Pediatrics
Opening Remarks
• Steven Costantino, Secretary, Executive Office
of Health and Human Services
• Christopher Koller, Commissioner, Office of
the Health Insurance Commissioner
• Michael Fine, MD, Director, Rhode Island
Department of Health
• William Hollinshead, MD, MPH, President,
Rhode Island American Academy of Pediarics
Children, Families and the
Medical Home:
Why do we need “CSI-Kids”?
David Keller MD
Project co-Director, CSI-RI
Objectives
After my talk, you should be able to:
• Describe the current health status of Rhode Island’s
children and youth
• Explain the healthcare needs of children that must be
met in rapidly changing healthcare environment
– Healthy children
– Children with special health care needs
• Name an example showing how RI’s children fit into
models proposed by the Affordable Care Act
How are the children?
#25 of 50
How’s their health?
#19 of 50
Why? Look at the details:
Indicator
Rate
Rank
MORTALITY
Infant
6.2 per 1000 births
23rd
Child
16 per 100,000 children
16th
Teen
40 per 100,00 teens
6th
NEWBORNS
Low birth weight
7.7 %
18th
CHILDREN
Lead level > 10 mg/dl
3%
Child maltreatment
15 per 1000 children
42nd
TEENS
Teen births
22 per 1000 teens
7th
Substance abuse
8%
30th
Furthermore
Indicator
Rate
EARLY CHILDHOOD
Enrolled in EI
11%
Eligible in HeadStart
40%
Overweight
25%
SCHOOL AGE
Chronic Early Absences
12%
4th Grade Reading
71%
4th Grade Math
65%
HIGH SCHOOL
Graduation
77%
Teens not in school/ not working
8%
Children with Special Health
Care Needs
• 17.3% of RI children have a special health care need
(per CSHCN screener)
– Allergies, developmental delay, ADHD, asthma
• More than 25% of CSHCN
– Behavioral problems, anxiety, depression, migraines, ASD
• More than 15% of CSHCN
• 97% have a “source of regular care”
• 30% got help with care coordination
From J Griffin, Analysis of National Survey of Children with Special Health Care Needs
Rhode Island Sample - 2009/10 DHHS
CHCSN are high risk
Medicaid Enrollees and Expenditures,
FY 2009
Disabled 15%
Elderly 10%
Disabled 43%
Adults 26%
Elderly 23%
Children 49%
Adults 14%
Children 21%
Enrollees
Total = 62.6 million
Expenditures
Total = $346.5 billion
NOTE: Percentages may not add up to 100 due to rounding.
SOURCE: KCMU/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.MSIS FY 2008 data were
used for MA, PA, UT, and WI, but adjusted to 2009 CMS-64.
But still, common things cost
the most
Why a Pediatric Medical
Home?
• Pediatricians (and FP, NP, PA) see children before
they start school
– Able to screen
– Able to refer
– Able to follow up
• Children and families with SHCN need help in
accessing medical and other services
• Coordinated care will assure that services are
used early and effectively, saving some cost now
and a whole lot later
The ACA is a scaffold to build on
In the ACA:
• Increase access:
– Covered lives
– Medicaid/ Exchanges
In Rhode Island:
• Medicaid expansion
• Exchange
• Transform care system:
– Focus on quality
– Teams/ Reporting/
Payment
• Beacon Initiative
• CEDARR (Health Homes)
• Innovation grants (asthma,
smoking)
• Payment Reform:
– Try new ways
– Take them to scale
• CSI-RI (MAPCP)
• ACO (Coastal)
1
5
The Medical Home:
A Practice with benefits
Used with permission of Ed Paul MD,
Yuma Regional Medical Center
American Academy of Pediatrics
and Medical Homes
Elizabeth B. Lange, MD FAAP
Past- President, RIAAP
Pediatrician, Waterman
Pediatrics/Coastal Medical
History
• 1967 – AAP first uses the term “medical home”
– Definition : One central source for a child’s pediatric records , especially children with
special health care needs
• 1980s – AAP broadens the medical home concept
– The provision of primary care that emphasizes the total health, education, family support and
social environment needs of the child
• 1990s – AAP publishes policy statement and partners
with Family Voices, focuses medical home on children
with special health care needs
• 2000s – AAP defines care coordination, includes parent
partners
• 2007 – AAP collaborates with AAFP, ACP, AOA to write
the Joint Principles of the Patience Centered Medical
Home
Joint Principles of the Patient
Centered Medical Home (PCMH)
• Developed in February 2007
• American Academy of Pediatrics (AAP) , American Academy of
Family Practice (AAFP), American College of Physicians (ACP),
American Osteopathic Society (AOA)
• Outlined characteristics of the PCMH
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–
–
–
–
–
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Personal physician
Physician-directed medical practice
Whole person orientation
Coordinated, integrated care
Quality and safety
Enhanced access
Appropriate payment
Source: http://www.medicalhomeinfo.org/downloads/pdfs/JointStatement.pdf
AAP Preamble to the Joint
Principles of the PCMH
• The AAP elaborated on the joint principles by
creating a preamble that advocates for the following
dimensions of the pediatric medical home
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–
–
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Family-centered partnership
Community-based system
Transitions
Value
Pediatric Medical Homes
Is it Patient Centered or Family- Centered?
IT’S BOTH!
Pediatric Medical Homes are a patient- and
family-centered partnership that is built on a
trusting, collaborative and working
relationship with families, respecting their
diversity and recognizing that the family is the
constant in a child’s life.
FCMH: Focused on
Prevention
Childhood is the time to build
health
Pediatric Visits: 2002-8
Healthy childhood lifestyles =>
prevented adult chronic
illness
Preventive care
Acute care
Chronic care
FCMH is when you can
improve population health
(the Triple Aim)
Pre/post surgical care
From 2003-2008 National Ambulatory Medical Care Survey (MD
office visits for children 0-21 yrs)
The Medical Home: Health Care Access
and Impact for Children and Youth
• Results of 2007 National Survey of Children’s
Health
• 56.9% of US children ages 1-17 years had a
medical home
• These children are more likely to have
preventive health visits and their medical and
dental needs met
Strickland, et al. 2011. Pediatrics 127(4); 604-611.
Medical Home Cost Savings
Families with children with special health care
needs (CSHCN) incur lower out-of-pocket
medical costs when their children receive
health care in a setting in which the carecoordination component of the medical home
is in place.
In turn, these families are less likely to report
financial stress attributable to medical
expenses incurred by those children.
Pediatrics 2011:128:892-900
Improved Outcomes Associated with
Medical Home in Pediatric Primary Care
• 6 conditions studied (asthma, diabetes, cerebral
palsy, epilepsy, ADHD, and autism).
• Results: some medical home measures correlated
with lower hospitalization rates.
• Higher chronic-condition management scores were
associated with lower ER usage.
Cooley, et al. Pediatrics. 2009;124(1);358-364
Colorado Medicaid and SCHIP PCMH
for low-income children
• Median annual costs $785 for PCMH children
compared to $1000 for control
• PCMH children in Denver with chronic conditions
had lower median annual costs ($2,275) than
those not enrolled in a PCHM practice ($3,404)
• 72% of children in PCMH practices had well child
visits, compared to 27% of controls
Kevin Grumbach, MD and Paul Grundy, MD, MPH Outcomes of Implement Patient Centered Medical Home Interventions, November 16, 2011
Patient-Centered Primary Care Collaborative at http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf accessed 3/22/11
Case Management Cost
Savings
In the fiscal years of 2007 – 2010, children age
20 and younger enrolled in the Community
Care of North Carolina networks for the
Division of Medical Assistance, cost the state
healthcare budget, on a per-member-permonth basis, 15% less than the non-case
managed children, resulting in a savings of
$238,000,000 for fiscal year 2010.
Milliman Report for the North Carolina Division of Medical Assistance, December 15, 2011
Community Care of North
Carolina
• Cumulative savings of $974.5 million over
6 years (2003-08)
• 40% decrease in hospitalizations for
asthma. 93% of asthmatics received
appropriate maintenance medications
• 16% lower ED visits
Kevin Grumbach, MD and Paul Grundy, MD, MPH Outcomes of Implement Patient Centered Medical Home
Interventions, November 16, 2011 Patient-Centered Primary Care Collaborative at
http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf accessed 3/22/11
In RI, The Time is NOW
• Multiple PCMH demonstrations and pilots have proven
the effectiveness of the medical home model of
primary care in improving clinical outcomes and
generating financial benefits to payers
• CSI-RI (adults) program shows a slowing of inpatient
admissions and cost trends at its PCMH sites, as well as
a reduction in inpatient admissions by 8%
• CSI-RI (adults) practices met >3/6 quality metrics, high
patient experience and a reduction in ER use for
ambulatory sensitive conditions
Why Pediatric Medical Home
Demonstrations?
• The time has come to harvest these medical home best
practices and apply them to pediatric populations for a variety
of reasons including:
– An investment in patient- and family-centered care for
children today will lead to healthier adults tomorrow
– Application of medical home for chronic care conditions
builds efficiencies in care between primary and subspecialty
care
– Parents receiving care in a medical home will begin to
expect these services for their children
– Employers will begin to use pediatric medical homes as a
selection criterion for their benefit plan purchase decisions
– Investment in the pediatric medical home enhances the
relationship with the member/family and provider network
which supports value proposition of insurers
Practice Transformation
Lessons Learned from CSI-RI (Adults)
1. Engage practices early in initiative design
2. Team based care is central
3. Measurement is hard, and requires strong
commitment from practices to work
4. Practices need to incorporate thinking about
measurement into their processes of care
5. Financial incentives can drive change in a
practice and in patient outcomes
Most important CSI-RI lesson
Change is possible with –
1. committed leadership
2. the right incentives
3. the proper support
1 + 2 + 3 + you = CSI-Kids
Thank you
Pediatric Centered Medical Home
Tina Spears, RIPIN
Our Family
Brothers
Ahanu, Taquonck, and River
The center of our family, our
boy Taquonck
Race to the Top
Early Learning Challenge
Michele Palermo, Associate Director
Rhode Island Department of Education
What Is The
Race To The Top
Early Learning Challenge?
•
A $500 million federal competitive grant program to help states build more
efficient and effective early learning systems for young children-infants, toddlers &
preschoolers-and their families.
- RI was one of 9 states to be awarded a grant
•
Intent was to “Challenge states to build a coordinated system of early learning and
development that ensures that many more children from low-income and
disadvantaged families, from birth to age 5, have access to dramatically improved
early learning and development programs and are able to start kindergarten with a
strong foundation for future learning.”
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RTT-ELC Projects
•The RTT-ELC grant work is organized by projects. Each project has a Scope of Work
(SOW) document approved by the Feds which includes a budget, staff, activities,
milestones and deliverables.
•Projects include:
―Program Quality Standards, Alignment, and Measurement
―Early Learning and Development Standards
―Child Assessment
―Early Learning Workforce Development
―Program Quality Improvement
―Early Learning Data System
―Grant Management
•Each Project is managed by a inter-agency Core Team which includes state staff
assigned to project activities and a liaison from the RI Early Learning Council
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Child Assessment:
Key Activities
•Provide professional development opportunities to support reliable child
assessment and to support the use of assessment data to inform practice.
• Expand the reliable use of Teaching Strategies GOLD in early learning programs.
―Early Intervention
―Community-based early care and education
―Technological supports
•Increase developmental screening rates
―Pediatric practices (B-3)
―Child Outreach (3-5)
―Issue intervention grants tied to screening results
•Develop or identify valid, reliable, and appropriate K-entry assessment and a
plan to pilot the K-entry assessment by the school year 2014-15.
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Developmental Screening
Blythe Berger, Team Lead
Rhode Island Department of Health
HEALTH-Developmental Screening
Support Primary Care Providers to increase screening rates
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Support the Implementation of screening in primary care
On-going Communication with Provider community
Coordinate efforts with other states engaged in similar work
Work with state Medicaid office around sustainability plans
Support Quality Improvement in practices
HEALTH-Developmental Screening
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Share Information
Short Term
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Support use of electronic screening tools
Share screening information electronically with KIDSNET
Enhancements to KIDSNET to accept information
Longer Term
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Share information from screening with electronic health records
Link HEALTH data with Department of Education data
HEALTH-Developmental Screening
Additional Supports
•
Funds to support practices to implement evidence based
interventions
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Funds for Physician Liaison
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Co-location of mental health or Parent education
Assist HEALTH in working with primary care providers
Quality Improvement
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Assist primary care providers to engage in quality improvement
activities that will increase screening rates
CSI-kids
Not just the little adults
Patricia Flanagan, MD
Hasbro Children’s Hospital
Issues Unique to Children and
Adolescents
• How do we operationalize the Patient
Centered Medical Home for child health care
systems versus adult health care systems?
• The “5 D’s”
5 “D’s”
• Development
– Health Care for children is a resource that
enhances children’s upward developmental
trajectory
– For children with chronic conditions, the
prevalence & severity change with age, so too do
the resources needed from the practice. Focus of
preventive services are habilitative vs
rehabilitative
Development
• Care coordination needs change as
children and teens grow and develop
• Developmental services focus on
maximizing potential and independence
rather than regaining loss
• Evaluation of PCMH must include
functional and developmental outcomes
• The Team is different
Development
• The special issues of adolescents and their
transition to adulthood, including
confidentiality and consent, must be
addressed
Dependency
• Community collaboration and
coordination must include early ed/child
care, schools, and families as key partners
• Services, supports and evaluation must
include the functioning of families,
recognizing that most children have
minimal autonomy in health care but that
this increases as part of the
developmental process
Differential Epidemiology
• Children are primarily healthy
• Epidemiology of chronic conditions differs
from adults
• Beyond obesity, mental health, and asthma,
categorical conditions are rare
Differential Epidemiology
• Prevention is critical, especially for obesity,
asthma and mental health
• Programs should address chronic conditions
non-categorically rather than disease-specific
• Children need access to pediatric sub-specialists
who can coordinate with each other as well as
the medical home, requiring considerable
clinician and practice resources.
Demographic Patterns
• Children have disproportionately high rates of
poverty
• The pediatric population is more ethnically
and racially diverse than the adult population
Demographics are Unique
• Understanding and addressing social
determinants of health is imperative to building
a effective health care system for children
• Evidence-based interventions (Head Start, NFP..)
and their coordination with medical homes is
essential and demands expanding the Team
• Addressing disparities (SES and racial/ethnic)
must be a priority in child health, with
implications for adult health
Dollars
• Payor Differences
• Return on investment
Similarities
• Care Coordination is an essential resource
• Continuity of care over time/transitions
• Centered around Patient, family and
community
• Comprehensive: Preventive/acute/chronic
• Culturally Competent and compassionate
Promise of CSI-Kids
• Practice transformation
• Data gathering and analysis at the practice level
• Payment reform that supports the need for nontraditional reimbursed services, rewards
wellness and optimal developmental progress
• Longer term ROI, more complex tracking of ROIcross sector (health, education, child protection,
JJ, economic..)
Next Steps
• Organizational structure to mesh with current
successful CSI structure
• Partner with community/payors/state resources to
start with improving rates of developmental
screening
• Improve the relationship between CEDARRS and
PCMH by building intentional collaborations, metrics
of care coordination
Actions
• 1. Join us at the stakeholders (providers,
payor, partners) meeting
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Date: Friday, March 1, 2013
Time: 7:30 – 9:00 AM
Location: RI Department of Administration, Conference room B
Address: 1 Capitol Hill, Providence, RI 02908
• Join committees to develop contracts, define
metrics, develop practice transformation
strategies
CSI Steering Committee
Executive Committee
Patient
Advisory Group
Marketing/
Communication
Working Committees
Data and
Evaluation
PTST
Practice
Reporting
Payment
Reform/
Contract
Service
Expansion and
Integration
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Questions
• Patricia Flanagan, MD, CoChair, Hasbro Children’s
Hospital
• Elizabeth Lange, MD, CoChair, Waterman Pediatrics
SINCERE THANK YOU!!!
To CSI-RI, EOHHS,OHIC, HEALTH
To RI Foundation
To RI AAP
And Mostly, to all of you who came to
hear about CSI-Kids!!